Help understanding HRT levels before I see GP

[thaneofglamour]

So, I have been on different forms of HRT for maybe 3 years now- none massively successfully. Eventually settled on Estradot patches and Gepretix nightly. A consultant has declared me not yet menopausal (even though I am 53) because I still have bleeds (I take the Gepretix nightly because other ways were causing various intolerances) which seem to fall in natural cycle. I'm really allergic to the patches and am vaguely wondering if dry , rash covered skin doesn't absorb as well?

For about 3 -4 months I had no bleeding and I thought halleluia as prior to this the bleeds had been awful. But now I have had two in the space of 2 months - and this recent one has had me so ill I was bedridden. It is still going on after 8 days and the blood is bright red. I have had a recent ish scan and a recent hysteroscopy which was clear. I am at the age where continuous HRT is usually prescribed and I just want the monthly agony of bleeding to get lost now. It's all getting confused in my and GP's heads with gallbladder issues , possible IBS and other crap - and I'd at least like to be able to get rid of one variable. I also suffer from hormonal nosebleeds which have come back this month. Anyone wise enough to know whether it's the oestrogen or the progesterone that needs upping? I am not on very high doses : Gepretix every night 100 mg and Estradot 50mg.

The pain and bleeding once a month is genuinely debilitating.

The BMS suggests 200mgs Utrogestan daily (different brand to what you're using but the same) for women who need to control the bleeding. Or you could try reducing your patch - is there a lower estrogen only one? Or try gel where you can titrate the amount more carefully- 2 pumps =50mcg patch but you could so 1.5 pumps.

Or the Mirena coil?

Or you could try Norethisterone daily . A lot of GPs don't seem to know about this but it is available as a separate tablet, and is the same progesterone as in patches. It's stronger than micronised progesterone.

I'm allergic to the gel.

I think the 200mgs may be the starting point so I'll see if I can go in with that. Thanks!

So, as an update , I went to GP :she was pretty useless really as I think she was stumped. The normal route for the symptoms I described is scans but I have had two and a biopsy (although have now discovered no one has ever seen any results for this). In the end I nearly said' jingling says I should be on 200 mgs.' but instead opined that raising the progesterone element might be a thing to try... so we will see.

After I wrote my OP , I spent a night writhing about in pain with stabbing pains in my left pelvis, night sweats, bright red blood and two nosebleeds.

I had to bring up endometriosis as a suggestion - she has now done a referral for them to look into this - by the time that comes round , I'll portably be post menopausal.

I am usually quite loyal to my GP surgery but this one was spectacularly useless. She actually yawned !

I wonder if you could take along the BMS advice on this?
I've linked to it a couple of times last week for other posters.

https://thebms.org.uk/wp-content/uploads/2023/04/14-BMS-TfC-Progestogens-and-endometrial-protection-APR2023-A.pdf

Page 3

Progestogen doses within HRT regimens

Based on Cochrane evidence, the suggested dose of progestogen given in a continuous combined HRT regimen would be a minimum of 0.5 mg/day of norethisterone or 2.5 mg/day of medroxyprogesterone acetate. For low-dose sequential regimens norethisterone a minimum of 1mg/day given for 10 days a month, oral micronised progesterone 200 mg/day for 12 days a month, medroxyprogesterone acetate 10 mg/day for 10–14 days a month or dydrogesterone 10 mg/day for 14 days a month would be suitable options.

The dose of the progestogen should be proportionate to the dose of estrogen. While no data is currently available on the endometrial effects of high doses of estrogen and the optimal dose of oral or vaginal progestogen in this context, women who require high dose estrogen intake should consider having their progestogen dose increased to ensure adequate endometrial protection (e.g. micronised progesterone 300 mg for 12 days a month instead of 200 mg in cyclical HRT regimens or 200 mg daily on a continuous basis instead of 100 mg in continuous combined HRT regimens).

Is 50mg Estradot high? I thought that was quite middling?

I have just looked at her notes and she wrote I had a dull continuous ache. She didn't write anything about the nosebleeds, nightsweats or the severe pain I described experiencing. Only what I feel today.

Did she take your blood pressure? Nosebleeds are a red flag for high BP for me as they were my mum’s only symptom when hers was dangerously high and about to have a stroke. It does sound like you have something extra going on - I am the same age as you and still having regular bleeds each month but they are like small normal periods. I take my progesterone cyclically to reflect this.

Can you ask for a referral to a menopause specialist? Your circumstances would warrant it, I’m sure.

The referral will take over a year...

I have been through ENT for the nosebleeds and they are definitely hormonal. It seems to be an unrecognised symptom of hormonal issues in perimenopause.

OP, have you looked at histamine?

There is also a oestrogen spray available in Ireland, I've actually forgotten the name but sometimes it seems to suit women with skin issues and can be used on forearms. Some women find it too strong though, even at one spray (I think 3 sprays is the equivalent of a 50 patch). Gel can also be used on outside upper arms, have you tried there already? And there are gel sachets as well as the pump bottle, have you tried both? Though I think the sachets are legs only.

Also you can reduce your oestrogen dose by cutting your patch in half diagonally (diagonally is just easier to make sure it's halved more accurately) if you can't get a lower dose patch. Might be worth trying a lower dose.

A few things ...

yes, I have tried spray and gel and allergic to both! I can't see why the gel sachets would be different? The allergy has become systemic now so I am on permanent anti histamines.

Second thing - why would I want to reduce oestrogen? This is what I don't understand about HRT. Wouldn't that make me more prone to the night sweats and stuff.

We have quite a good HRT nurse (don't know why they made me see GP to be honest) so I might ask to see her although appointments with her are like hen's teeth.

To clarify - wherever I put the gel I was allergic to it - it was by far the worst of all the options.

A 50mcg patch is medium.

But this is never a one size fits all.

How much estrogen you absorb is down to your skin and a load of other things. The same applies to Utrogestan (micronised progesterone.)
Some women find HRT gives them heavy bleeds, others none at all or hardly any.
I have a heavier bleed on my HRT compared to a friend on a higher dose of estrogen who hardly bleeds at all - we are roughly the same age and take the same type.

So...the first step according to the BMS is more progesterone. OR changing to Norethisterone which is stronger.